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Gastroenterology Coding Alert

Punch Up Your E/M Claims With Prolonged Service Codes

Published on Sat Feb 05, 2005

But make sure you're abreast of all the rules before using codes

Reporting an evaluation and management that takes longer than usual can be tricky business. For example, if your practice doesn't use prolonged service codes when a patient's mental incapacities increase the service time, you could be missing out on legitimate payment.

On the other hand, if you report prolonged service codes when some other course of action would have been more appropriate, your office could land in hot water. Here is a closer look at the prolonged service codes, when to use them, and when you're better off not using them.

Prolonged Services for More Than a Few Minutes
 
Before even considering prolonged service codes, you need to know a couple of vital rules.
 
First, these codes are designed for physicians "who spend an inordinate amount of time, specifically 30 minutes, greater than the AMA's stipulated time limit for a given level of E/M service," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Translation: If the gastro takes 10-15 minutes longer than normal to complete an E/M service, you should not report a prolonged service code.

The second rule you must remember is that prolonged service codes are add-on codes, so they must be tagged to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. Do not report prolonged service codes alone, and never attach them to procedure codes.

Prolonged Service Codes Depend on Setting

Which prolonged service code set you use will directly relate to the setting; you must know where the service took place, or the claim could go out with the wrong codes.

Example: An established male patient with symptoms of stress-induced incontinence reports to the office, and the gastro performs a level-two E/M service. The visit takes 45 minutes, and level-two established patient E/M services typically take about 15 minutes, so a prolonged service code should accompany the E/M code on this claim.

The gastroenterologist provided prolonged services in this situation. On the claim, you should:
 

  •  report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making) for the office visit
     
  •  report +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) for the prolonged service time 
     
  •  attach ICD-9 code 788.32 (Stress incontinence, male) to 99212 and 99354 to account for the patient's incontinence.
     
    When reporting prolonged services, use 99354 for the first hour of outpatient prolonged service time and +99355 ( ... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour for outpatients.

    Exception: But if the above prolonged service took place in an inpatient setting, use:
     
  •  99231 (Subsequent hospital care, per day, for the E/M of a patient ...) for the E/M service
     
  • +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service; first hour [list separately in addition to code for inpatient evaluation and -management service]) for the first hour of prolonged service time
     
  •  +99357 ( ... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for each additional half-hour.

    Who Pays for Prolonged Services?

    All payers do not accept prolonged service codes, so if you're not absolutely sure that your carrier accepts the codes, do not report them. In Falbo's area, "Medicare pays for them, but the other [payers] are case-by-case," she says.

    Good advice: Before reporting prolonged services, "query your top payer classes [on prolonged services] and obtain something in writing as an addendum to their managed-care contract," Falbo says.

    Who Needs Them?

    There are no hard and fast rules about what types of patients need prolonged services; your individual office and your patients will dictate whether the services are needed. However, Falbo says some gastro patients who may be candidates for prolonged services include:  

  •  patients about to undergo an intensive therapy such as hepatitis C care, photodynamic therapy (PDT), stretta procedure, gastric ulcer care plan, etc.
     
  •  patients unable to communicate in a standard manner due to mental incapacities, deafness, or a language barrier
     
  •  patients who are non-compliant (e.g., a patient with mental incapacities does not feel comfortable with the physical touch involved in the exam, so administering E/M services takes longer than normal)
     
  • patients who need to have intense lifestyle changes explained to them due to their condition (cirrhosis patients, etc.).

    Time Raises E/M Level in Certain Cases

    Some longer-than-normal E/M services require you to upcode the E/M level, but the visit must meet certain conditions before you do this.

    Don't raise the E/M level when the gastro takes longer to provide an E/M service than normal. You can increase the E/M level only if the physician provides a higher level of service, Brink says. For example, the gastro is performing an in-office, level-four new patient E/M service for a patient who speaks Spanish primarily, and only knows some broken English and common phrases. Due to the communication challenges, the visit takes 80 minutes rather than the standard 45.
     
    On the claim, you should: 

  •  report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) for the office visit
     
  •  attach 99354 to account for the extra time.
     
    Raise the E/M level when the gastroenterologist spends more than 50 percent of the face-to-face time counseling and coordinating care for the visit, Falbo says.
     
    For example, if the gastro's notes indicate that he performed a level-four new patient E/M service in the office that took 80 minutes and he spent 45 of those minutes counseling the patient, you should raise the E/M level and forget about prolonged service codes. On the claim, you should:
     
  •  report 99215 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity) for the E/M service
     
  •  include specific documentation on the 45 minutes of  counseling to strengthen your claim.

    Expert Advice: Document Service Start/Stop Times

    Recording start/stop times on the claim can only make your prolonged service reporting better, because time is of the essence when circumstance extends an E/M session, Falbo says. 
     
    "The gastro must document the start and stop times of prolonged care, and demonstrate what he or she did during the prolonged service time. This documentation substantiates, in the medical record, that they did spend the 30 minutes or more required" to use the first-hour prolonged service codes, she says.

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